Health plan costs - managed care

Insurer Uses Patients' Personal Data to Predict Who Will Get Sick"[P]reventable readmissions... [cost] Medicare alone $15 billion annually. That's why Medicare launched an initiative a few years ago that penalizes hospitals that see too many patients readmitted too soon.... Now insurance companies are also taking a stab at a solution.... Independence Blue Cross ... runs algorithms on the huge amounts of health data at its disposal: billing claims, lab readings, medications, height, weight and family history. It also throws in information about the client's neighborhood, including poverty rates.... The computer algorithm sifts through all that information and pops out a score for each individual patient, identifying those it deems at highest risk." (Kaiser Health News)

Taxpayer-Funded CO-OPs Struggle to Survive"After receiving $2.5 billion in taxpayer dollars from the federal government, the vast majority of nonprofit insurance companies created under the Affordable Care Act recorded losses in revenue.... 23 of these entities were created to foster competition in areas where few options are available. Now, CoOportunity, a CO-OP created to serve Iowa and Nebraska, will be liquidated. Some lawmakers question the viability of the remaining 22 CO-OPs." (The Daily Signal)

Health CO-OPs under the ACA: Promise and Peril at the 5-Year Mark"The nongovernmental, state-delimited CO-OP program [created under the ACA] was to 'foster the creation of qualified nonprofit health insurance issuers to offer qualified health plans in the individual and small group markets.' However, the CO-OPs (health insurance providers) should not be confused with accountable care organizations (coordinated health care providers). In this Viewpoint, we review the central tenets of the CO-OP program, assess its current state of implementation, and describe its future challenges." (JAMA)

Industry Group to Back Results-Focused Healthcare Payments"A coalition of some of the nation's largest health care systems and insurers vowed on Wednesday to change the way hospitals and doctors are paid -- placing less emphasis on the sheer amount of care being delivered and more on improving quality and lowering costs.... The private coalition includes, among others, Partners HealthCare, the powerful Boston health system that oversees Brigham and Women's and Massachusetts General hospitals; Ascension, the nation's largest Catholic and nonprofit health system; Aetna, a national for-profit insurer; and Health Care Service Corporation, which operates five state Blue Cross plans." (The New York Times; subscription may be required)

The Latest Research on Accountable Care Organizations"[The author] would give ACOs another five or so years before drawing any strong conclusions about what they can do. Even a few years of generally positive results is insufficient to declare victory. It's reasonable to be optimistic, but cautiously so. A lot could still go wrong." (The Incidental Economist)

More Employers Limit Health Plan Networks But Seek to Preserve Quality"Those employers who are going to stay in the game -- which is the majority of them -- in many cases have to [improve] what they're covering. They have to offer the essential health benefits, they must meet affordability for the premiums and they have a looming Cadillac tax [on very generous health plans] in 2018. They now have to use the managed care tools that they all abandoned 15 years ago. So the answer is narrow networks[.]" (Kaiser Health News)

Massachusetts Wastes One Third of Health Spending, State Report Concludes"Main drivers of excess spending included patients returning to hospitals for preventable reasons and emergency-room visits that better primary care could have warded off, the state's Health Policy Commission concluded, citing data from 2012. The commission estimated between $14.7 billion and $26.9 billion in wasteful spending that year, representing between 21% and 39% of total health expenditures. The commission said the numbers were in line with waste at the national level, underscoring the challenges for a complex national health system that is stretching coverage to millions more people under the Affordable Care Act." (The Wall Street Journal; subscription may be required)

[Opinion] Payment Reform: Flat Facility Fees & ACOs Aren't Enough"The explosive growth of hospital costs is one of the key culprits in the nation's high health care spending. Nonetheless, attempts to reform hospital payment methodologies are usually greeted with fierce criticism from the industry. The latest clash, which stems from a CMS proposal to consolidate facility fees, offers an opportunity to review why hospitals are so expensive, to detail some of the larger issues with hospital billing practices and how they contribute to increasing health care costs, and to explore some ideas for reform." (Health Affairs Blog)

The Path Forward: Understanding What Participants Say and Do Uncovers Opportunities to Enhance Defined Contribution Plan Design"Plan sponsors and participants agree a 401(k) plan should focus on outcomes at retirement.... Professional investment managers don't necessarily change their investment mix each day. So why enable participants to change investments daily? ... Despite hard economic times, participant borrowing has not dramatically increased.... Participants want to retain their retirement benefit but may not realize the value their 401(k) plan provides through its fiduciary oversight and institutional pricing." (Northern Trust)

Many Health Insurers to Limit Choices of Doctors, Hospitals"This fall, Indiana's new online health-insurance marketplace will present some tough choices for consumers ... Similar situations are likely to occur around the country, as details emerge about the coverage available through the new consumer marketplaces created by the federal health law. Many of the plans will include relatively few choices of doctors and hospitals. In some cases, plans will layer on other limits, such as requirements that patients get referrals to see specialists, or obtain insurer authorization before pricey procedures." (The Wall Street Journal; subscription may be required)

Selecting and Strengthening Employee Assistance Programs (PDF)"Comparison of the data by each year revealed an overall increase in the size of covered employee populations of +17% ... However, this result varied by type of EAP. The Health Plan EAP group experienced significant growth in covered employees (+58%). Organizations that offered both EAP and carve-out [Mental Health Managed Care] programs had an increase in covered employees of +11%. In contrast, Free-standing EAPs had almost no change over time[.]" (Employee Assistance Society of North America (EASNA))

Patient Is Out of Network, Out of Luck"[Castleman's Disease sufferer Jalal] Afshar's fight with Kaiser highlights the growing tension in healthcare over how to eliminate wasteful spending without compromising the care of the sickest, most expensive patients. Under pressure to curb ballooning medical costs and hold down premiums in advance of a massive expansion of health coverage, insurers are increasingly forming smaller networks of physicians and hospitals. But some experts worry these cost-control measures could go too far." (Los Angeles Times)

Health Care's 'Dirty Little Secret': No One May Be Coordinating Care"Coordinated care is touted as the key to better and more cost-effective care, and is being encouraged with financial rewards and penalties under the 2010 federal health care overhaul, as well as by private insurers. But experts say ... communication failures ... remain disturbingly common." (Kaiser Health News)

If This Was a Pill, You'd Do Anything to Get ItVery extensive analysis of the effects of chronic care on the healthcare system, and efforts to improve outcomes while containing costs. "With chronic illnesses like diabetes and heart disease you don't get better, or at least not quickly. They don't require cures so much as management.... This ... is the core truth, and core problem, of today's medical system: Its successes have changed the problems, but the health-care system hasn't kept up." (The Washington Post)

[Opinion] The Coming Failure of 'Accountable Care'"The ACO concept is based on assumptions about personal and economic behavior -- by doctors, patients and others -- that aren't realistic. Health-care providers are spending hundreds of millions of dollars to build the technology and infrastructure necessary to establish ACOs. But the country isn't likely to get the improvements in cost, quality and access that it so desperately needs." (The Wall Street Journal)

[Opinion] Your Prevention Plan Does Not Save Money -- Yet Again"Companies are facing a crisis in health care costs, yet spending zillions trying to save money through prevention, when they really need to be doing things that will actually save money. One thing you can do is to focus your energy on the outliers in your benefit plans. Make sure they have the right diagnoses and treatment plans. That will save big dollars." (Cracking Health Costs)

Focus on Obamacare Delays Mental Health Parity Law"Mental health advocates say a landmark 2008 law meant to expand access to millions of Americans has gotten back-burner treatment by the Obama administration because of its relentless focus on the Affordable Care Act. As a result, key details are missing from the Mental Health Parity and Addiction Equity Act, awaiting a final rule from the administration that supporters say is 'imminent.'" (Politico)

Wellness Programs Get Booster Shot from Feds"While the experts agree that the new ACA focus on wellness can play a major role in curtailing employer healthcare costs, [a] Philadelphia-based [employment attorney] warns that the discriminatory aspects of the standards-based plans might still lead to litigation.... To avoid that potential for lawsuits, group health plans may choose to offer more limited type of wellness plans of the participatory type (paying for health club dues, putting a gym on the premises, providing wellness educational materials, etc.), which are not subject to the same rules." (Human Resource Executive Online)

Obesity, Lack of Insurance Cited in U.S. Health Gap"The United States spends more per person on healthcare than any other nation but lags on many important health measures amid higher rates of obesity and heart disease and worse infant mortality rates than other rich countries.... Americans overall fared the worst among the countries in the report when it came to nine areas: infant mortality; injury and homicide rates; teen pregnancy and sexually transmitted diseases; HIV infection and AIDS; drug abuse; obesity and diabetes; heart disease; lung disease; and disabilities." (Reuters)

The Managed Care Backlash on Health Care Costs: Evidence From State Regulation of Managed Care Cost Containment Practices"During the late 1990s, there was a substantial cultural, media and legal backlash against the cost-containment practices of managed care organizations (particularly, HMOs).... [T]he backlash had a strong effect on health care costs, and can statistically explain much of the rise in health spending as a share of U.S. GDP between 1993 and 2005 (amounting to 1% to 1.5% of GDP).... [The author concludes that] managed care was largely successful in keeping health care costs on a sustainable path relative to the size of the economy." (Maxim L. Pinkovskiy, MIT Economics)

Employers Tackling Costs of Misdiagnosis with Clinical Integration Solutions"[D]ata showing that even many of the best-designed workplace programs don't go far enough to address the core underlying problems in our healthcare system.... [M]isdiagnosis unfortunately remains a major workplace problem -- resulting in absent workers, poor health outcomes, wasted healthcare dollars, decreased productivity, and increased health and disability premiums.... Many of the country's leading employers have shown that, by integrating and collaborating with vendors' healthcare programs, they actually improve the quality of care their employees receive -- and positively impact their healthcare costs." (Human Resource Executive Online)

Determining Discounts for Health Care Costs"Healthcare reform has grabbed the headlines with various cost-saving initiatives for employers and individuals alike. However, the potential for significant savings is available without any required change to the current structure.... This paper covers the most frequently asked questions about the calculation and evaluation of medical discounts, highlights various methods for estimating discount differences, and discusses how discount differences impact the overall medical cost to the employer." (Milliman)

Summaries of Benefits and Coverage Now Available!Wolters Kluwer Law & Business - ftwilliam.com now offers the newly required Summaries of Benefits and Coverage (SBC). Contact us for a demo and if you have more than just a few plans, ask us about our batch printing option. (ftwilliam.com)

Earn your CEBS (Certified Employee Benefit Specialist) DesignationCEBS is the most respected benefits designation in the industry. Co-sponsored by the International Foundation and the Wharton School, the program is an essential step for those who want to advance in the employee benefits industry. Click the link to learn More. (IFEBP (International Foundation of Employee Benefit Plans))

Wellness Programs and Value-Based Health Care Third EditionFrom the International Foundation, this detailed survey report examines popular wellness programs in the United States and Canada. Ways of identifying health risks, promoting physical activity, and providing health-related education are included! (International Foundation of Employee Benefit Plans)

Value-Based Purchasing Spearheads Health and Wellness"Self-insured health plans that want to adopt value-based benefits have at least three major tasks at hand: (1) finding and purchasing from the high-performing provider in the area; (2) designing a benefit that will steer employees to those high-performing providers; and (3) emphasizing effective preventive care, so chronic ailments don't become acute and costly." (Thompson SmartHR Manager)

How Will the Election Impact the Affordable Care Act?Following the election, join the International Foundation of Employee Benefit Plans Webcast to explore the impact on health care reform, the next steps for Congress and the next steps for plan sponsors. Register now for this November 8 Webcast! (IFEBP (International Foundation of Employee Benefit Plans))

The most important thing you can do today -- Vote!Let each citizen remember at the moment he is offering his vote that he is not making a present or a compliment to please an individual -- or at least that he ought not so to do; but that he is executing one of the most solemn trusts in human society for which he is accountable to God and his country. (Samuel Adams in the Boston Gazette, April 16, 1781) (BenefitsLink.com)

Ten Modifiable Health Risk Factors Cause More Than 20 Percent of Employer Health Care Spending"Examining ten of these common health risk factors in a working population, [the authors] found that similar relationships between such risks and total medical costs documented in a widely cited study published in 1998 still hold. Based on [a] sample of 92,486 employees at seven organizations over an average of three years, $82,072,456, or 22.4 percent, of the $366,373,301 spent annually by the seven employers and their employees in the study was attributed to the ten risk factors studied." (Health Affairs)

Summaries of Benefits and Coverage Now Available!Wolters Kluwer Law & Business - ftwilliam.com now offers the newly required Summaries of Benefits and Coverage (SBC). Contact us for a demo and if you have more than just a few plans, ask us about our batch printing option. (ftwilliam.com)

Summaries of Benefits and Coverage Now Available!Wolters Kluwer Law & Business - ftwilliam.com now offers the newly required Summaries of Benefits and Coverage (SBC). Contact us for a demo and if you have more than just a few plans, ask us about our batch printing option. (ftwilliam.com)

408(b)(2) Provider Disclosures: What Do I Do Now?From the International Foundation -- The 408(b)(2) is an ongoing obligation -- Plan sponsors, funds, and providers are still discussing what their disclosures mean for plans and plan participants. Learn about what you need to do today. Order today! (International Foundation of Employee Benefit Plans)

Large Employers Look to On-Site Health Clinics to Reduce Costs and Absenteeism"A study this year ... found that only 8 percent of employers across the country currently have such clinics. But among big companies -- where large numbers of employees mean a clinic can more easily amass enough patients to justify its cost -- these facilities are becoming more common. A recent study ... found that 46 percent of large employers offered at least one on-site clinic, up from 37 percent the previous year." (The Washington Post; free registration required)

New & Innovative. A Conference Developed Just for You!Health, benefits & wellness play huge roles in transforming your employees and organization. Gain new ideas & actionable solutions to do just that when you join us in April. Secure your seat now for the lowest rate. Details at www.BenefitsConf.com. (Health & Benefits Leadership Conference)

New & Innovative. A Conference Developed Just for You!Health, benefits & wellness play huge roles in transforming your employees and organization. Gain new ideas & actionable solutions to do just that when you join us in April. Secure your seat now for the lowest rate. Details at www.BenefitsConf.com. (Health & Benefits Leadership Conference)

Engaging Employers on Paying for Health Care That's Proven to Work"This brief presents findings on employers' familiarity with -- and reactions to -- concepts related to paying for care based on demonstrated achievement on quality. The focus groups identified potential barriers to employers' involvement and the information and messaging that would facilitate their participation in payment initiatives." (Robert Wood Johnson Foundation)

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